Basic Information
| Provider Information | |||||||||
| NPI: | 1194770412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOE D RIDDLE MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053297621 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053297621 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | RIDDLE | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4053297621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10240 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 202257462001 | 01 | OK | BCBS | OTHER |